Heart Border Research Articles

A Straight Left Heart Border: A New Radiological Sign of a Hemopericardium

Detection of a cardiac injury in a stable patient after a penetrating chest injury can be difficult. Ultrasound of the pericardial sac may be associated with a false negative result in the presence of a hemothorax. A filling in of the left heart border inferior to the pulmonary artery, called the straight left heart border (SLHB), is a radiological sign on chest X-ray that we have found to be associated with the finding of a hemopericardium at surgery. The aim of the present study was to determine if this was a reliable and reproducible sign. This was a prospective study of patients with a penetrating chest injury admitted between 1 October 2001 and 28 February 2009, who had no indication for immediate surgery, and were taken to the operating room for creation of a subxiphoid pericardial window (SPW). The chest X-ray was reviewed by a single trauma surgeon prior to surgery. A total of 162 patients with a possible occult cardiac injury underwent creation of a SPW. Fifty-five of the 162 patients (34 %) were noted to have a SLHB on chest X-ray and a hemopericardium confirmed at SPW. The sensitivity of the SLHB sign was 40 %; specificity, 84 %; and positive predictive value, 89 %. (p = 0.005, Odds ratio 3.48, lower 1.41, upper 8.62). The straight left heart border is a newly described radiological sign that was highly significant in predicting the presence of a hemopericardium and should alert the clinician to a possible occult cardiac injury.

Cardiac involvement of lung cancer mimicking myocardial infarction

A 58-year-old man (a heavy smoker), without prior medical history, was admitted to the Department of Cardiology in the emergent diagnosis of acute coronary syndrome with ST segment elevation in the third hour of retrosternal pain. The initial ECG revealed sinus rhythm 85/min, left anterior fascicular block, QS pattern in V1–V3 with ST-segment elevation in the leads V2 through V6 (up to 2 mm in V2–V3), with symmetric negative T waves in the leads I, aVL, V2–V5 (Fig. 1). Laboratory tests, except for a small leukocytosis (11 × 109/L, N to 10 × 109/L), and elevations of troponin T (30 ng /L, N to 14 ng/L), were within normal limits. Urgent coronary angiography was performed, which showed critical changes in the distal circumflex branch narrow artery (< 2 mm), with no significant haemodynamic atherosclerosis in other arteries. Due to the location of the stenosis and artery calibre, coronary angioplasty was not performed. Despite typical pharmacological treatment, pain relief was not achieved. The subsequent ECG recorded persistent ST-segment elevation with negative T waves in precordial leads, without a change in troponin values (the II. troponin: 27 ng/L and the III: 28 ng/L). Based on radiological images of the chest, a tumour in the left lung with obliteration of the left heart border was suspected. Transthoracic echocardiography demonstrated the presence of a tumour sized 10 × 7 × 11 cm with involvement of the pericardium (without evidence of fluid), and probably the anterior wall of the left ventricle. To differentiate the cardiac mass, we performed cardiac magnetic resonance imaging and confirmed an anterior mediastinal tumour, causing extensive atelectatic changes in the left lung and infiltrating the anterior wall of the left ventricle (Figs. 2, 3). The patient was referred to the oncology centre where metastatic small cell carcinoma of the left lung was diagnosed. Three months after the start of chemotherapy, the patient died. The most common neoplasms associated with cardiac metastasis are lung cancer, oesophageal cancer, lymphoma, breast cancer, leukaemia, stomach cancer, and melanoma. Their symptomatology is largely dependent on the size of the tumour and its location. Myocardial infiltration by tumour cells may lead to the occurrence of arrhythmias and cardiac conduction, and less non-specific ST segment changes. In this case, the clinical and ECG changes initially showed a myocardial infarction with ST segment elevation anterior wall. However, subsequent ECGs, serial measurements of cardiac troponin and results of imaging studies did not confirm the initial diagnosis. In the era of invasive treatment of myocardial infarction, it is necessary to consider other causes of ST-T changes in the ECG and increased troponin values. Extended cardiac diagnosis and a multidisciplinary approach are often necessary to determine the correct diagnosis.

Congenital Absence of pericardium

A 30- year-old physically active male presented to us for evaluation of left sided chest pain which was non-exertional in nature. He described it as being of pricking type and non-radiating .His past history was not significant. Physical examination revealed a non-palpable apical impulse with no other abnormal findings. A chest x-ray (P-A view) revealed levoposition of heart, loss of the right heart border (hidden by spine) and prominence of pulmonary artery segments(Fig 1).A “tongue” of lung interposing between aorta and pulmonary artery was not evident in chest x-ray in this case. ECG was taken in the supine position with precordial leads placed in the standard position , which revealed right axis deviation, right bundle branch block(RBBB) pattern and poor R wave progression(Fig2). Transthoracic echocardiography revealed unusual windows with marked lateral displacement of apical windows. Lateral placement of the transducer was also necessary for parasternal axis views. Right atrium and right ventricles were mildly dilated. Echocardiography excluded other structural heart diseases (Fig 3 and Fig 4). As the above findings were suggestive of the diagnosis of congenital absence of pericardium, further investigations including CT chest and cardiac MRI were done to confirm the diagnosis. CT thorax(Fig 5), also suggested absence of pericardium. Axial T1 weighted cardiac MRI revealed markedly rotated axis of the the heart with mildy dilatation of ventricles. Lung was seen insinuating between aorta and pulmonary artery. Pericardium was absent(Fig 6). Thus, the diagnosis of total absence of pericardium was confirmed. Patient was advised to continue activities without limitation and was not referred for any kind of intervention. DOI: http://dx.doi.org/10.3126/njh.v9i1.8350 Nepalese Heart Journal Vol.9(1) 2012 pp.53-55

The Snoopy sign

Figure 1 : Congenital complete absence of the pericardium. (A) Characteristic posteroanterior radiograph of the patient with congenital complete absence of the pericardium. Note the marked levoposition of the cardiac silhouette, loss of right heart border, prominent main pulmonary artery, flattening and elongation of the left heart border (snoopy sign) and lung tissue interposing between the main pulmonary artery and the aorta (arrow). (B) Chest CT mediastinal setting shows characteristic interposition of lung tissue (arrow) between the aorta (AO) and the pulmonary artery (PA). (C) Chest CT coronal setting shows flattening and elongation of the left heart border (snoopy sign). (D) Chest CT axial setting showing leftward and posterior rotation of the heart and the absence of the pericardial layer over the posterior portion of the heart.

SU‐E‐T‐621: Is Non‐Coplanar Tangential Beam IMRT Better Than the Field in Field Technique for Left Sided Whole Breast Radiotherapy?

Purpose: To study the comparison of 4 field non‐coplanar tangential beam IMRT (nctbIMRT) with FIF technique for early stage left‐sided, instead widely used comparison of coplanar IMRT with FIF. Methods: Retrospective study was done on 10 patients left‐sided, intact, whole breast RT. Followings are the 2 simple factors:d' and Δd, where d' ‐distance between skin and posterior border of PTV and Δd‐distance between posterior border of PTV and heart at largest heart and breast CT‐slice. Both are on line that passes though center of heart. With these, patients were classified into 4 classes based on PTV size and distance of heart from PTV as follows: Class 1: large PTV, close heart; 2: large PTV distant heart; 3 small PTV, close heart; 4: small PTV, very close heart. Results: For patients with heart close to PTV, nctbIMRT showed better PTV coverage and better organs at risk sparing. The average D95 of PTV and D5 of heart for FIF were found to be 96.2% and 83.9%, 95.1% and 8.27%, 92.38% and 55.3% and 92.7% and 46.8% for class 1, 2, 3 and 4, respectively. For nctbIMRT, D95 of PTV and D5 of heart were 99.7% and 15.6%, 97.25% and 9.3%, 97.42% and 29.8% and 96.8% and 35% for class 1, 2, 3 and 4, respectively. Conclusion: Unlike coplanar IMRT, nctbIMRT containing tangential beams, as shown in study, is advantageous in that it reduces volumes receiving low dose in critical structures. This method of classification is more realistic than making generalisation based on the average dosimetric parameters of all patients considered. While all patients in Class 1, 3 and 4 are beneficiaries of the nctbIMRT technique, patient in Class 4 presenting with heart adjacent to PTV benefited the most. On the other hand, FIF may be preferable for Class 2 patients with distant heart to the PTV.

An unusual cause of haemoptysis in a smoker

A 33-year-old Caucasian male smoker presented to our rapid access lung cancer clinic with a single episode of moderate haemoptysis and no other respiratory or systemic symptoms. There was no...

Faux anévrisme du ventricule gauche du sujet jeune : à propos de trois cas

Pseudoaneurysm of the left ventricle is a rare late complication of myocardial infarction. So-called non-coronary forms have been described in young people. In this context, we report three cases. Mr. M.B., aged 20, consulted for chest pain associated with palpitations. Cardiovascular examination found a pulsatile, expanding precordial bulging and a mesocardiac systolo-diastolic murmur. We noted a sinus rhythm with ventricular extrasystoles on ECG. The chest radiograph showed cardiomegaly and aneurysmal deformation of the left lower heart border. Doppler echocardiography showed a large left ventricular apical pseudoaneurysm. Mrs. O.B., aged 23, was admitted for biventricular heart failure and in whom the examination found a systolic murmur in the apical area. ECG showed a regular sinus tachycardia, left atrial and ventricular hypertrophy. The chest radiograph showed cardiomegaly and aneurysmal deformation of left middle and lower heart borders. Doppler echocardiography showed a large left ventricular apical pseudoaneurysm. Mr. I.S., aged 24, admitted for the management of congestive heart failure. The patient had non-specific laboratory inflammatory signs, a sinus tachycardia and extrasystoles on the ECG. Chest radiography showed a discontinuation at the posterior arch of the sixth rib, a cardiomegaly and a neurismal dilatation of the left lower heart border. Doppler echocardiography showed a large apical pseudoaneurysm of the left ventricle.

A Heart With Extra Rooms

![Figure][1] [![Graphic][3] ][3] A 55-year-old woman, 12 years after aortic and mitral valve replacement, presented with shortness of breath. The chest radiograph showed a prominence along the left heart border (A, arrow) . Cardiac computed tomography (B, D) revealed a large

Multiple Thrombosis Caused by Arrhythmogenic Right Ventricular Cardiomyopathy

A 68-year-old man was transferred emergently to our department because of multichamber intracardiac thrombosis. Enhanced computed tomography revealed multichamber thrombosis in the right atrial appendage, right ventricular outlet tract. and left atrial appendage, with localized aneurysm of a much enlarged right ventricle. He underwent thrombectomy and valve repair. Here we report a rare case of arrhythmogenic right ventricular cardiomyopathy with multichamber intracardiac thrombosis.

Radiographic Evaluation of Central Venous Catheter Position

To determine the best radiographic landmark for the cavoatrial junction (CAJ) using electrocardiographic-gated, 64-row multidetector coronary computed tomographic angiography (CTA). Institutional Review Board approval was obtained. Patient age, sex, weight, and height were recorded. The CAJ was localized by 2 readers using multiplanar CTA, cross-referenced with a scout topogram. Designated radiographic landmarks (the carina, intersection between the bronchus intermedius and the right heart border, and the inflection of the right heart border) were assessed for visibility and vertical distance from the CAJ. Sixty consecutive CTA studies (39 men, 21 women; age range, 27 to 98 y; mean±SD, 55±15 y) were analyzed. The closest radiographic landmark to the CAJ was the intersection between the bronchus intermedius and the right heart border (0.9±0.8 cm above the CAJ), visible in 71% of patients. The second closest radiographic landmark was the inflection of the right heart border (1±0.8 cm above the CAJ), visible in 84% of patients. The carina was visible on 100% of topograms, 4.2±1.1 cm above the CAJ. There was no strong correlation between age, weight, height, or sex and the visibility or distance of landmarks from the CAJ. The intersection of the bronchus intermedius with the right heart border and the inflection of the right heart border are the closest radiographic landmarks to the CAJ. When these landmarks are not identifiable, the most uniformly visible radiographic landmark is the carina.

Visualizing pericardial inflammation as the cause of acute chest pain in a patient with a congenital pericardial cyst: the incremental diagnostic value of cardiac magnetic resonance

A 29-year-old female presented with chest pain radiating to the back and worse on inspiration. An ECG was unremarkable. d-Dimer was 0.54 µg/mL (<0.5 µg/mL). Chest X-ray showed an abnormal left heart border ( Panel A ). CT pulmonary angiogram found no evidence of pulmonary embolism, but showed a 7.5 × 5.4 × …

Giant left atrium in a patient with prosthetic mitral valve

A 76-year-old female patient presented complaining of chronic cough and dyspnoea. She underwent mitral valve replacement and tricuspid annuloplasty for rheumatic mixed mitral valve disease with severe tricuspid regurgitation 13 years ago. Clinically, the patient had features of congestive cardiac failure. Chest X-ray revealed asymmetrical cardiomegaly with the right heart border extending to the right lateral chest wall. Echocardiography demonstrated …

Partial anomalous pulmonary venous connection (RCD code: II-3C.0)

A 48-year-old woman was admitted to our institution with a year’s history of uncharacteristic chest pain episodes and decrease in exercise tolerance. A CT lung scan performed nine months earlier revealed an anomalous vein arising from the right lower pulmonary lobe and draining into the inferior vena cava. A chest radiogram performed 2 months prior to the admission showed a curved shape adjacent to the right heart border. Right heart catheterization revealed: normal systolic, diastolic and mean pulmonary artery pressures, normal pulmonary resistance and insignificant shunt volume. Pulmonary artery angiography demonstrated an anastomotic vessel between the aberrant pulmonary vein and the right upper pulmonary vein. The patient was diagnosed with Partial Anomalous Pulmonary Venous Connection in form of Scimitar syndrome. Given a mild character of symptoms, no signs of the right-sided heart volume overload, insignificant shunt fraction and normal pulmonary circulation parameters, the patient was qualified to a conservative treatment with a close medical observation. JRCD 2013 ; 1 (2): 39–41 Key words: partial anomalous pulmonary venous connection, scimitar syndrome, left-to-right shunt, pulmonary hypertension

Mitral valve size measurement in North Karnataka by using cardiac sizer: A cadaveric study

Background: Heart is a vital organ of circulatory system. Valves maintain the unidirectional flow of blood. Mitral valve (MV) prevents the backflow of blood into the left atrium. For the proper functioning of the heart, all valves should be intact. MV prolapse and regurgitation is the main cause of MV replacement. Mean circumference of MV varies from person to person. Aim of the present study is to measure the average size of the valve in the cadavers of North Karnataka region by using cardiac sizer, which would help in the selection of prosthetic valve in the cardiac surgery. Materials and Methods: This study was carried out on 50 cadaveric adult human hearts. Left atrium was opened along the left border of heart so as to expose the mitral orifice. Then, the diameter of the valve was measured by using cardiac sizer, whereas circumference was calculated manually. Number of mitral valve cusps and papillary muscles were observed. Results: The mean annular circumference and diameter of the mitral valve was found to be 8.03 ± 0.82 cm and 2.56 ± 0.32 cm, respectively. Majority (72%) of the mitral valves had the circumference ranging from 7.53 to 8.47 cm and the diameter ranging from 2.4 to 2.7 cm. Conclusion: The size of mitral valve in the North Karnataka region was found to be less as compared to the other studies. This study might help cardio-thoracic surgeon as well the prosthetic valve manufacturing companies for the rough estimation of the mitral valve size.

Cor triatrium presenting as mitral stenosis and severe anemia

Cor triatrium presenting as mitral stenosis and severe anemia

Woolly Hair Nevus Involving Entire Occipital and Temporal Scalp

Dear Editor: Woolly hair is an abnormal variant of the fine, curled hair on the scalps of non-Black people. These abnormal hairs are curly, short, thin and sparse. Woolly hair nevus is a rare condition that is characterized by curly hair in a circumscribed area of the scalp1. A 20-year-old woman visited our hospital complaining of sparse and curled hair on her scalp. On clinical examination, we observed a well-defined patch of abnormal hairs over the occipital and lower temporal area. The abnormal hairs were curly, short, and appeared thinner and lighter than the other hairs on the scalp. The scalp surface on the lesion showed mild erythematous macules and patches (Fig. 1A, B). The patient reported that these findings have been present since she was 1 year old. She had a known past history of pectus excavatum but no other skin problems or visual abnormalities and no medical or family history. On histopathologic examination, hair follicles revealed a wavy appearance with perifollicular infiltration of the inflammatory cells (Fig. 1C). The diameter of five woolly hairs and five normal hairs on vertex area were measured by phototrichogram (Folliscope 2.8; LeedM, Seoul, Korea). The mean diameters of the normal vertex area hairs and the woolly hairs were 0.086 mm (Fig. 2A) and 0.041 mm (Fig. 2B), respectively. Chest X-ray showed right heart border obliteration, and left atrial enlargement was shown on electrocardiography. We consulted with the department of cardiology for diagnosis of this abnormal finding, but no abnormalities were found in complete medical checkups. Other laboratory tests results were within normal ranges. These findings were consistent with a diagnosis of woolly hair nevus. Fig. 1 Well-defined patch of abnormal curly hair over the occipital and lower temporal area. (A) Right 90° side view. (B) Posterior view. (C) Wavy hair follicles with perifollicular infiltration of the inflammatory cells (H&E, ×40). Fig. 2 Mean hair diameters were measured by phototrichogram. (A) Normal hairs on the vertex (0.086 mm). (B) Abnormal hairs on the occipital scalp (0.041 mm). Woolly hair is characterized by curly and fine hair. It is presented at birth and is usually the most severe during childhood. The growth rate is usually normal, but the hair may not grow longer than a few centimeters, and it may be caused by a shortened growth cycle1. Hutchinson et al.2 classified three groups of woolly hair: autosomal dominant hereditary woolly hair, autosomal recessive familial woolly hair, and woolly hair nevus. Woolly hair nevus is a rare condition associated with unruly, curly hair. These hairs tend to be lighter in color, smaller in diameter than the surrounding normal hair without an increase in fragility, and appears to be sparse1,3. It has been commonly reported that the affected hair is smaller in diameter than normal hair and the area of involved scalp has been described as being several centimeters and round in shape1,3,4. Our patient displayed woolly hair nevus on her entire occipital and lower temporal area. The involvement area is much larger than that of other cases in previous reports. To the best of our knowledge, this type of widespread woolly hair nevus has never been reported in the literature. About 50% of woolly hair nevi are associated with an ipsilateral pigmented or epidermal nevus4. Our patient showed no other abnormalities except pectus excavatum, but it is uncertain whether the pectus excavatum is associated with the woolly hair nevus or not.

An Extremely Large Coronary Aneurysm Associated with a Quadricuspid Aortic Valve in an Adult Patient

A 68-year-old woman exhibited an increasingly protruding mass on the left heart border on chest X-ray. Transthoracic echocardiography revealed an echo-free mass in the anterior pericardial space. Transesophageal echocardiography revealed blood flow from the proximal left anterior descending coronary into a large coronary artery aneurysm measuring 61 mm × 51 mm in diameter and a quadricuspid aortic valve with a small cusp between the left and right coronary cusps. Coronary angiography demonstrated the presence of a coronary aneurysm connected to the proximal left coronary anterior descending artery. A giant coronary artery aneurysm and pulmonary artery fistulas extending from the left and right coronary arteries were confirmed by surgeons and successfully treated with surgery.

Abstract 255: CT Imaging of Pediatric Heart Deformation During Chest Compressions

Background: Adequate chest compression (CC) depth is associated with increased survival to hospital discharge, yet specific data guiding CC depth targets in children are lacking. Current guidelines for pediatric CCs are based on extrapolation from adults, animal models, and expert consensus. Given this lack of data, investigation into the biomechanical effect of CCs on the pediatric thorax is warranted. Methods: Three non-injurious CC simulations were performed on a single 7 year-old post-mortem human subject with intended compression depth of 0%, 15%, and 25% of external thoracic depth. A Phillips CPR Force Deflection Sensor replica was positioned at the inter-nipple line of the subject. Force was statically applied to reach the desired compression depth. Non contrast-enhanced CT imaging was obtained for each compression level. External thoracic depths were measured at the inter-nipple level from the most anterior to most posterior skin surface at midline. Internal depths were measured from the posterior sternal border to the anterior border of the corresponding vertebral body. Left ventricular volumes were calculated using three-dimensional multiplanar reconstruction and a 4-level modified Simpson method. Results: Intended 25% compression resulted in change of 25mm in external chest depth and 20mm of internal depth (a 16.4% and 29.6% change, respectively). Total left ventricular volume (inclusive of myocardium and ventricular cavity) was reduced by 8.8% (62.7cm 3 to 57.2cm 3 ). Right ventricular volumes were not measured due to difficulty in right heart border visualization, but subjective deformation of the right heart was greater than left. Conclusions: This is the first reported CT visualization of thoracic contents during compression of the pediatric chest. Our results indicate a proportionally greater decrease in internal thoracic depth than external depth for a given compression depth. Previous studies extrapolating the desired compression depth from CT-data have assumed internal compression directly proportional to external compression depth. These studies may overestimate the target depth necessary to achieve a given amount of internal thoracic compression.

Thymoma Presenting as Chest Pain

A 75-year-old ex-smoker male with hypertension and diabetes presented to the emergency room with pressure-like, mid-sternal, nonradiating chest pain for 2hours, not associated with dyspnea, diaphoresis, palpitations, fever and pleurisy. Electrocardiogram and cardiac enzymes were normal. Chest x-ray revealed a rounded mass along the left heart border (Figure 1A). A contrast-enhanced computed tomography scan of the chest defined it as a well-circumscribed, solid, lobulated anterior mediastinal mass measuring 6.2 [times] 5.3 [times] 9.5cm consistent with thymoma (Figure 1B).

CLINICAL ANALYSIS OF III ATRIOVENTRICULAR BLOCK AND SHOCK CAUSED BY ACUTE PANCREATITIS

ObjectivesAcute pancreatitis is very common, but in this case typical symptoms such as acute and persistent abdominal pain did not occur. The first complaint was syncope, III atrioventricular block, shock....